SI Leader and Tutor Application

Personal Information

First Name
Last Name
Middle Initial
CID
Local Address	Street/Box No.
	City
	State Zip
Phone Number
ASU E-mail
Class Standing
GPA
GPA Major
Major
Minor
Universities you have attended (other than ASU)
Have you been employed by ASU?	Yes No
If you have been employed by ASU, list when and where
Have you even been convicted of a felony?	Yes No
If you have been convicted of a felony, please explain in detail
How did you hear about this position?
Have you received a letter from Financial AId approving you for Work Study status?	Yes No

Employment History

Most Recent Employer Name
Employer Address	Street/Box No.
	City
	State Zip
Immediate Supervisor’s Name
Immediate Supervisor’s Phone
Start Date
Employment Hours
Briefly describe your duties and responsibilities
Reason for Leaving
Second Most Recent Employer Name
Employer Address	Street/Box No.
	City
	State Zip
Immediate Supervisor’s Name
Immediate Supervisor’s Phone
Start Date
Employment Hours
Briefly describe your duties and responsibilities
Reason for Leaving

Course Information

List all the courses for which you are capable of providing SI support and/or tutoring.

	Course Number: Course Name: Instructor: Grade:
	Course Number: Course Name: Instructor: Grade:
	Course Number: Course Name: Instructor: Grade:
	Course Number: Course Name: Instructor: Grade:
	Course Number: Course Name: Instructor: Grade:

Your experiences

	Please indicate and briefly discuss your tutoring or peer mentoring experience, if any.
	Please indicate any past, present and anticipated involvement in other activities or jobs (on or off campus).
	Please indicate any special skills/qualifications.

References

Indicate the two faculty members who will be submitting reference letters (via e-mail, fax, or by mail):

	Faculty Name: Department:
	Faculty Name: Department:

Consent

I certify that all the information provided by me in connection with my application, whether on this documentor not, is true and complete, and I understand that any misstatement, falsification, or omission of informationshall be grounds for refusal to hire, or if hired, termination.

Additionally, I understand that as a condition of employment, I will be required to provide legal proof of authorization to work in the U.S.

Your Signature
Date

Faculty Reference Information

Faculty may submit the reference information to:

E-mail: danica.guthrie@angelo.edu

Fax: (325) 942-2776

Mail: Office of SI and ASU Tutor Center
Porter Henderson Library (A307/3rd Floor)
Angelo State University
San Angelo, TX 76909

Who Are You?

SI Leader and Tutor Application

Faculty Reference Information

Angelo State University

Find us on…